Approach to Altered Mental

Status & Seizure

HO TEACHING
PRESENTER : DR EMIR
Introduction
• Consciousness is being awake, alert, and aware of your
surroundings.
• Stupor (Latin – to be stunned) – deep sleep/unresponsiveness
from which patient can be arouse only with vigorous/continuous
stimulation.
• Coma (Latin – deep sleep or trance) – state of unresponsiveness in
which patient lies with eyes closed and cannot be aroused even
with vigorous stimulation.
4 things you need to conscious

• Sugar
• Oxygen
• Intact neural pathways
• Intact reticular activating system (RAS)

Anything that disturbs or disrupts these

can cause alterations in mental status.
Sugar & Oxygen

•Sugar (in the form of glucose) is the fuel on which the brain runs.
•Oxygen is needed by brain cells to carry out metabolism.

A sudden lack of blood flow to the brain

or lack of oxygen will shut the brain
down in 5 to 10 seconds.
Neural pathway

• Groups of nerves that run through the brain

• Carry signals from the brainstem to various destinations in the brain
• These pathways can be disturbed by trauma, tumors, chemicals (drugs) or
electrical interference (that which cause seizures).
• Stroke, epilepsy, and trauma are different events that affect these
pathways resulting in altered mental states.
Intact RAS
• reticular activating system (RAS) — An area of nerves in the
brainstem, thalamus and hypothalamus that controls
consciousness.

AMS is a strong
indication of insult to
the central nervous
system.
AEIOU-TIPS mnemonic
Major causes of altered mental status are AEIOU-
TIPS:
•Acidosis, Alcohol •Trauma, Tumors,
•Epilepsy/Seizures Temperature
•Infection •Insulin
•Overdose •Psychosis, Poisoning
•Underdose, Uremia •Stroke
Acidosis
Acidosis is the increase in the acid level in the body. Its causes
include:
•diabetes
•shock
•poisoning
•overdose
•kidney failure
•impaired breathing
Alcohol
• A depressant that inhibits the brain
• As the blood alcohol level rises, reason and judgment are impaired.
• Intoxicated patients may progress from stupor to coma to death primarily
from respiratory depression and arrest.
• These people cannot maintain their airway and
are in danger of aspirating their saliva or vomitus.
Epilepsy/Seizures

•occurs when the neural pathways become disturbed

by excessive discharge of electricity in the brain
•can affect either part of the brain or the whole brain
itself
•Alcohol withdrawal in addicts may cause seizures
due to disruptions in the neural pathways.
Infection

•Usually causes high temperatures and inflammation

that affect the brain’s neural pathways, the brainstem
and supplies of sugar and oxygen
•Infection of the central nervous system, such as
meningitis or encephalitis, may cause an altered mental
status.
Overdose

•Barbiturates and narcotics (for example, heroin) are drugs

that can suppress brainstem function.
•Narcotics can slow the respiratory centers of the brain
resulting in a lack of oxygen.
•Cocaine can produce extreme CNS stimulation resulting in
seizures and strokes.
Underdose/Uremia

•Some medical conditions may cause altered mental status

when the patient does not take adequate amounts their
prescribed medication.
•Diabetic coma may occur in diabetics who do not take
adequate amounts of insulin.
•COPD patients can develop an altered mental status from
retaining too much carbon dioxide when they do not use
medicines delivered by their metered-dose inhaler.
Trauma/Tumors/Temp

•Trauma to the head can cause damage to vessels and brain

tissue.
•Tumors can affect neural pathways and the brainstem,
neural pathways, oxygen and sugar.
•Temperature extremes have a dramatic impact on all four
elements of consciousness.
Insulin

•The insulin-dependent diabetic produces an insufficient amount of

insulin and must inject insulin into the body.
•If the diabetic forgets to eat, overexerts, or takes too much insulin,
there is a serious shortage of glucose (hypoglycemia).
•The brain, which is very sensitive to sugar supplies, begins to shut
itself down.
•Another condition called hyperglycemia may occur when there is
not enough insulin in the blood.
Psychosis

•A mental illness that commonly affects personality, for

example, schizophrenia and manic depression.
•Delirium and acute brain syndrome are specific types of
psychoses where the patient displays disorientation,
memory-loss, and lapses in
consciousness.
Poisoning

•Mechanism that causes unconsciousness varies greatly depending

on the substance.
•Carbon monoxide prevents oxygen from reaching the brain.
•An overdose of tricyclic antidepressants can cause hypotension,
cardiac dysrhythmias and a lack of oxygen and sugar.

Poisoning can occur through inhalation,

injection, absorption and ingestion.
Stroke

•A stroke occurs when a portion of the brain is damaged due to

interruption of blood flow (lack of sugar and oxygen).
•Strokes affecting one side of the brain may cause altered mental
status.
•Massive strokes involving the brainstem will cause coma.
•Transient ischemic attacks (TIAs) can be thought of as "mini-
strokes"—symptoms of these events subside completely within 24
hours.
Seizure
Definition
- A seizure happens because of abnormal electrical activity in the
brain
The Differential Diagnosis of Seizures
Syncope Metabolic disturbances
• Vasovagal syncope • Alcoholic blackouts
• Cardiac arrhythmia • Delirium tremens
• Orthostatic hypotension • Hypoglycemia
Psychological disorders Hypoxia
• Panic attack Transient ischemic attack (TIA)
Migraine
Classification of seizure
Generalized seizures Partial ( focal, local) seizures
• Simple Partial Seizures
◦ Tonic – clonic seizures (Grand mal)
(consciousness not impaired)
◦ Absence seizures (Petit mal)
◦ Tonic seizures • Complex Partial Seizures
◦ Atonic seizures (consciousness impaired)
◦ Myoclonic seizures
Generalized seizures (whole brain involve)
• Tonic seizure — A brief seizures (usually < 60 seconds)
consisting of the sudden onset of increased tone in the
extensor muscles
• Clonic seizure —A sudden onset of alternate involuntary
muscular contraction and relaxation in rapid succession
• Tonic-clonic seizure — A type of seizure involving the entire
body, usually characterized by violent rhythmic muscle
contractions and loss of consciousness.
Generalized seizures (whole brain involve)
• Atonic seizure — A type of seizure that consist of a
sudden loss in muscle tone (usually <15 seconds)
• Myoclonic seizure — Tonic type of seizure in very short
duration (milliseconds) that may involve the whole body
or part of the body
• Absence seizure — brief seizure, usually <15 seconds,
causes loss of awareness associated with automatisms
Simple partial seizure
Signs/symptoms
• Tingling starts with fingers and moves proximally (epileptic
march)
• Twitching of muscles or extremities
• Head turning
• Visual changes
• Dizziness
• Aura
•Sensation of smelling odors, seeing lights or colors, feeling of
butterflies in the stomach
Complex partial seizure

 Focal seizure with associated loss of consciousness &

automatisms

 Signs and symptoms

• Confusion and no memory of the episode
• Abnormal behavior, possibly not noticed by others
• Staring, sense of déjà vu, visual hallucinations
• Aimless moving, fidgeting, repetitive motion
• Smacking, chewing lips
Differential Dx
Causes of Seizure
By age group
6 months to 3 years
• Common: high fever (febrile seizures)
• Metabolic abnormalities
•High/low sugar or sodium levels
•Low calcium or magnesium levels
•Vitamin B6 deficiency
2 to 14 years
• Often the cause is unknown
• May be the result of measles, mumps, other childhood diseases
Causes of Seizure-cont
By age group
After age 25
• Head injury (trauma)
• Stroke
• Tumor
• Alcohol withdrawal
•Seizure and altered mental state are two signs of delirium
tremens, a sign of alcohol withdrawal
•May result in death (35% if untreated; 5% if recognized and
treated early
APPROACH
Approach

•Danger
•Respond
•Airway
•Breathing
•Circulation
•Disability (neurologic)
•Exposure
Danger
•Observe the surroundings, the patient’s body
position, bystanders and other clues that may
indicate danger to you, your crew or the patient.
•Decide if it safe to enter the scene and if you need
additional resources.
Respond - Mental Status
•AVPU mnemonic
•Alert
• Responds to Verbal stimuli
• Responds to Pain
•Unresponsive
Approach
•Airway, breathing and circulation (ABCs) must
be monitored closely.
•An altered mental status & seizure especially
requires that you attend to the airway,
breathing & oxygen therapy to meet patient
needs and proper positioning.
•Consider the use of an airway adjunct if the
airway cannot be maintained.
Approach

•If patient is still seizing

•Position on side (no spinal injury) for oral drainage
•Do not force anything into mouth
•Do not restrain
•Loosen restrictive clothing
•Protect from injury
•Consider cause of seizure
Airway
• How do you assess? • What interventions can you make?
 Open the airway Provide supplemental oxygen if
needed
check pulse-oxymetry.
Intubate if GCS <8 comes mostly
from trauma literature
• What do you look for?
Check to see that the airway is maintain C-spine collar if
patent history unknown
Are there secretions or vomit that
needs to be suctioned?
Any foreign body?
Airway
• Head tilt/chin lift for
medical patients

• Jaw thrust for

trauma patients
with suspected
cervical spine injury
Airway
• Note abnormal sounds.
• Snoring
• Denotes obstruction by the tongue
• Oropharyngeal or nasopharyngeal airway to maintain patency
• Gurgling
• Suction may be needed to clear fluids.
Airway
• Stridor or inability to speak
• May denote airway
obstruction
• Heimlich or other maneuvers may
be needed.
• Patient may be having severe
allergic reaction.
• Positive-pressure ventilation,
epinephrine, and rapid transport
may be needed.
Airway
• In unresponsive patients
• Maintain an open airway.
• Oropharyngeal or
nasopharyngeal airway may be
needed for continued airway
control.
• Suction may be
needed to clear
airway
Airway: rapid differential

• Loss of protective reflexes • Stridor

• Many causes… Infection
• epiglottitis, tracheitis, croup
• Overdose
Foreign body aspiration
• Intracranial catastrophe
• Oropharyngeal swelling
• Anaphylaxis
• Angioedema
• Infections
• Ludwig’s angina
Breathing

• How do you assess? • What options are there for

• Rate interventions?
• Depth • Supplemental O2
• Pattern • Positive pressure support (CPAP,
BiPAP)
• Auscultation (bilateral and equal?)
• Intubation
• Pulse oximetry
• Decompression
• End Tidal CO2
Breathing

• Look, listen, and feel

method
• Look for chest and abdominal
movements, accessory muscle
use, and retractions.
• Listen for air movement and
abnormal sounds of breathing.
• Feel for warm air from the lips
and mouth.
Breathing

• Rhythm
• Regular/Irregular
• Quality
• Breath sounds —
present and equal
• Chest expansion —
adequate and equal
• Minimum effort of breathing
• Depth (tidal volume) – visible
chest rise
Breathing: rapid differential

• Hypoxia • Tachypnea
• pneumonia, CHF, PE, COPD • Profound Met Acidosis
DKA/AKA
• Respiratory depression Sepsis
• opioids, brainstem injury
• Asymmetric exam
• Hypercarbia = “CO2 narcosis”
• Pneumothorax, hemothorax
• Large effusion
Circulation

• How do you assess? • What options are there for

• Distal pulses interventions?
• Blood Pressure • IV fluids
• Cardiac rhythm • Blood products
• Distal perfusion • Cardioversion
• Cardiac pacing
• Inotropes/vasopressors
Circulation

• Pulse check
• Radial pulse in children and
adults
• Brachial pulse in infants
• Carotid pulse in unresponsive
adults and children when
unable to feel a pulse in the
arm
Circulation

• Observe for obvious bleeding.

• Assess for color, temperature, and condition (moisture).
• Skin
• Nail bed
• Conjunctivae and mucous membranes
• Note cyanosis.
• Signs of hypoperfusion — pale, cool, clammy skin.
Circulation: rapid differential

• Hypotension
• Shock differential (distributive, neurogenic, obstructive,
hypovolemic, cardiogenic)

• Hypertension
• Hypertensive crisis
• Sympathomimetic abuse (cocaine, amphetamines, designer
drugs)
• Elevated ICP (mass lesion, hemorrhage)
• Compensatory reflex (cushing’s, ischemic stroke)
Circulation: rapid differential - cont

• Tachycardia
• Broad differential…

• Bradycardia
• Drug overdose (digoxin, lithium)
• Organophosphate exposure
• Uremic encephalopathy
• Hyperkalemia
• Neurogenic shock
Disability (neurologic catastrophe)

•How do you assess? •What interventions can

GCS/IVPU
Pupillary exam
Look for seizure activity
Evaluate extremity
movement
Signs of elevated ICP
you make?
Anti-epileptics
Elevate head of bed
Hypertonic agents
Disability: rapid differential

• Conjugate eye deviation • Signs of elevated ICP

• Stroke (toward lesion) • Mass lesions
• Seizure (away from lesion) • Stroke with swelling
• Hemiparesis • ICH
• Stroke
• Post-ictal state
• ICH
Exposure
• What does this mean? • What are you looking for?
• Fully undress patient • Trauma
• Head to toe rapid exam • Patches
• Lines, tubes, fistulas
• Rashes, wounds/decubitus
ulcers
•
•Now that you have treated life
threatening emergencies and have
calmed the patient down…..
Time to figure out what is going on by
full history taking
Take History

Diagnosis usually based on history!

History obtained
• Patient
• Witnesses
 Personal history
Seizure
Preictal
• any warning? Abdo pain, fear, unpleasant sensation
• What was patient doing?
• Asleep or awake?
• Precipitating events (head injury, source of
infections – CNS/middle ears/sinus/abdo/respi/cvs)
• Was patient well? Any fever?
History
Ictal Post ictal
• Responding during spell vs consciousness • How did they feel after (Drowsy?
impaired Confused? Tired?)
• Did child remember spell • How long until return to baseline?
• Repetitive behaviors during spell – lip • Sustained any injuries?
smacking, etc
• Previous history of seizures, febrile
• Body movements – part or all seizures
• Cyanosis
• Incontinence
• How long, how many, how often
• Gaze deviation, eye rolling
Personal history
AMS
• Baseline – be specific
• How often do they see the patient?
• What is the “change” they observed?
• changes in sleep-awake cycle
• onset, location, evidence of trauma, information about home environment,
medications in home
• Family/friends: focal signs prior to LOC
Past Medical history

• Chronic illnesses (hepatic or renal failure, endocrinopathies,

COPD, DM, CCF)
• Medication - Immunosuppression/ recent cancer treatment
• Previous history of alcoholism or Wernicke's encephalopathy
• Physical, emotional, mental disabilities
• Recent hospitalizations
• Recent dialysis
Social history

• Home environment and social support systems

• nutritional status (thiamine deficiency, Vit B12 and folate
deficiency)
• Any recent life-altering social or emotional events
• any recent scuba diving (? air embolism) or foreign travel
(malaria)
◦ Drugs that lower seizure threshold

 Β lactam antibiotics

 Quinolones

 INH

 Acyclovir

 Theophylline
Physical Exam
• Complete physical exam
Check vital signs
Check pupils for size, symmetry and reactivity to light
Abnormal pupillary response may indicate depressed brain function or
brain injury.
Occular movements and oculovestibular response
DXT
Pulse oximetry
Neuro – signs of increased ICP, cranial nerves, Motor, sensory, cerebellar,
reflexes
Physical Exam-cont
Look for physical evidence of diseases that may have precipitated
altered mental status/seizure
• cardiac ischemia/AMI (abnormal heart sounds, murmurs)
• CHF (tachypnea, abnormal heart sounds, murmurs, rales,
hepatomegaly, pedal edema)
• pneumonia (tachypnea, rales, bronchial breathing)
• Intra-abdominal infections (peritonitis, ascites)
Physical Exam-cont
• liver failure - jaundice, spider nevi, caput medusae, ascites,
hepatomegaly or shrunken hard liver, genital atrophy,
gynecomastia
• Thyrotoxicosis - enlarged thyroid, autonomic hyperactivity,
exopthalmos, pretibial myxedema
• toxidromes eg. anticholinergic toxicity (red flushed skin,
mydriasis, tachycardia, hypertension, urinary retention, decreased
bowel sounds)
 Investigations
ECG / cardiac monitoring lumbar puncture
Venous blood  Indicated if there is suspicion of
meningitis or encephalitis
FBC, electrolytes, LFT, TFT, CRP, blood
cultures, viral titer, glucose – Cells
– Gram stain
Arterial blood
– Glucose / protein
pH, pO2, pCO2, HCO3, lactate
– Cultures
Urine drugs of Abuse? (if suspected)
Other test
Urinalysis, UPT
Urine
Imaging EEG
CXR, CT Brain
Investigations
• EEG
• Diagnosis of epilepsy
• Classification of seizures / epilepsy
Treatment: Care for adult and pediatric patients

• After seizure stops

•Identify and treat injuries
•Suction airway if necessary
•If cyanotic, provide oxygen (12-15 lpm NRB or 2-6 lpm nasal
cannula—adults and peds)
•Monitor vital signs and respirations
•Encourage transport
Treat fever
•Acetominophen
•Cooling - tepid sponging
Treat seizure
• Correct any irreversible causes :
- Electrolytes/Glucose
• Specific drugs :
1) Bezodiazepam Group
- IV Lorazepam 0.1 mg/kg
- IV Diazepam 0.15 mg/kg
2) IV Phenytoin 20mg/kg at <50mg/min + BP monitoring & arrythmias

If still fitting, give :

- IV Phenobarbital 20mg/kg at 50 mg/minute
- IV Propofol 2mg/kg bolus then infuse 2mg/kg/hr
Consider antibiotic
•Early Abx shown to be important in severe infections
•Start Abx before sending to CT if high suspicion of
infection
•Draw blood cultures prior to starting Abx
Treatment
• minimize sensory overload by limiting the number of care-
givers and ensuring a quiet enviroment
• allow family members to remain in constant/frequent
attendance
• do not leave patients unattended in the hallway and
ensure that the bed side-rails are up
Case
• Miss B. E. A.M.
22 y.o/tunisian/female/single

Alleged MVA at 12mdnight

- Car vs divider , at MEX seri kembangan
- Patient was a passenger and sleeping during the accident,unsure what was
happening
- Took xanax 2 tab (1mg) and drank 1 cup of beer prior to accident due to
persistent pain over the left knee
- Previously had ?knee surgery 1 yr ago at Qatar

- Post trauma, Appears drowsy when ambulance came

- GCS was full upon arrival to ED
Otherwise,
• Unsure LOC - pt was sleeping in the car, woke up in the hospital
• No Ent bleeding/Vomiting/retrograde amnesia/headache/blurry of vision
SOB/Chest pain

Social history:
• Already stayed in malaysia for 5yrs , Just graduated 10 days prior accident
• she is an alcohol consumer & always go to clubbing and drinks alcohol
• friend was unsure of any recretional drug used
• Patient told she was pregnant 2 months.
O/e: Ix
FBC: wbc 9.34, hb 10.9, plt 175,
- GCS was full upon arrival to ED
hct 32.1
- Warm peripheries
- CRT <2sec
- good pulse volume

vital sign:
bp : 105/60mhg
pr : 85 bpm
spo2 97% under RA
GM 4.1mmol
Examinations
Head
No abrasion/hematoma/active
bleeding Pupils: 3mm/3mm reactive
bilaterally
Maxilofacial Structure
No abrasion/hematoma/active
bleeding
Cervical Spine and Neck
on cervical collar
no abrasion/bruises /step deformity
Chest
trachea central,equal chest rise,no
open chest wounds, no crepitus, chest
spring -ve
lungs : clear, equal air entry
CVS : drnm
Abdomen
Soft, non tender, not distended, Pelvic
spring -ve
FAST scan : no free fluid, FH (+)
Examinations
Musculoskeletal system
Right UL :
Superficial Laceration wound 3cm in length at elbow, no active bleeding, not exposing
muscles/bone, no active bleeding, ROM full
Left UL :
Superficial Laceration wound 3cm in length at elbow, no active bleeding, not exposing
muscles/bone, not active bleeding, ROM full
Bilateral LL:
ROM full
moving all toes , not active bleeding
Management
 Keep cervical collar
 IVD 1 pint NS run fast
 T. PCM 1g stat
 Refer surgical for Cerebral Concussion
 Refer Ortho TRO T6-T7 fracture
Refer O&G for fetal assessment
Upon review by surgical team
Upon review noted patient no responding to call, responding to pain stimuli for a
very short time
not obey command
pinpoint pupil, not reactive to light

imp:
1. TRO drug intoxication
2. unlikely cerebral concussion
Plan:
- Suggest for ED to take urine screening for drugs
- GCS charting
- pupillary charting
Investigation
Urine for drug:
Positive: amphetamine, methamphetamine, cannabis, benzodiazipine
IMP: Substance abuse in pregnancy
 result well informed to Surgical team & to refer medical team for withdrawal
syndrome
Upon review by medical team
O/E
- Alert
- GCS full oriented to tpp
- hydration good
- Responding to call
- No alcoholic breath
Imp: No sign of intoxication/withdrawal
plan :
- Suggest for ortho and o&g input
- w/o for sign of withdrawal
- start IVD 3 pints NS/24hrs while in ED
Upon review by Ortho team
no cervical/spinal/paraspinal
tenderness Imp:
1. Treat as STI
able to move neck sideways without
2. unlikely T6-T7 fracture.
pain, able to sit up without pain
Plan:
Asia Charting : motor & sensation
off cervical collar
intact
d/c ortho
- reflex UL and LL : brisk
TCA SOC in 1 week to review symptoms
- no clonus
pcm prn
- babinsky downgoing
P/R examination : anal tone/sensation/
BCR intact
Upon review by O&G team
• no pv bleed
no abdominal pain
never done scan before
Tas
- s/fh+ shown to mother
- crl= 10w+2d
- redd;1/3/18
Imp : alleged mva with normal pregnancy
Plan :
- for early booking
- repeat scan 2/52 to confirm redd at own centre
•Patient was then allowed home with police report
made & accompanied to police station by narcotic
officer